Provider Demographics
NPI:1831467356
Name:PHS CENTER FOR LIFE SC 2ND FLOOR
Entity type:Organization
Organization Name:PHS CENTER FOR LIFE SC 2ND FLOOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGINBOTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-368-3162
Mailing Address - Street 1:1150 VARNUM ST NE RM 102
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-854-7074
Mailing Address - Fax:202-854-7825
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:ST. CATHERINE'S HALL, 2ND FLOOR
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2107
Practice Address - Country:US
Practice Address - Phone:202-269-7074
Practice Address - Fax:202-372-0026
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHFD01-0212207V00000X, 282N00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC029833400Medicaid
VA09810714Medicaid
MD005145400Medicaid
090006Medicare PIN